Improved diabetic control in adolescents using the Penject syringe for multiple insulin injections

The latest developments in insulin injection devices

The next several years promise dramatic changes in the treatment of diabetes, many of which will be driven by rapidly developing technology. Today's patient with diabetes has ready access to more information about the disease and its treatment options. As a result of this increased knowledge base, insulin-treated patients have become more autonomous in the management of their diabetes and may be better prepared to participate in making informed choices regarding insulin delivery devices. As with any insulin regimen, diabetes educators are encouraged to provide ongoing patient education and follow-up to assure optimal use of these new technologies.

Type 1 diabetes mellitus in a routine diabetes clinic: the association of psycho-social factors, diabetes knowledge and glycaemic control to insulin regime

In controlled trials intensified diabetes therapy including multiple insulin injection regimes has been shown to improve glycaemic and microvascular disease outcomes in insulin dependent diabetes but this is not clear in routine outpatient practice. We undertook a pragmatic cross sectional study of 200 patients with Type 1 diabetes aged 18-50 years. There were 108 on two insulin injections/day (conventional) and 92 on four injections/day (multiple) with no significant difference for age, sex, social class, body mass index, diabetes duration, hypoglycaemia rate or complications prevalence. The relationship of insulin injection regime used with diabetes knowledge, psychological factors and glycaemic control outcomes was evaluated. Percent glycated HbA1c concentrations (normal range < 5.5%) were worse in the multiple injection group (7.5 +/- 1.7 vs. 6.8 +/- 1.4%, P < 0.001) (mean +/- SD). Their scores for diabetes knowledge (72.5 +/- 8.2 vs. 69.0 +/- 9.8, P < 0.01) were better but treatment satisfaction (29.9 +/- 5.1 vs. 28.5 +/- 6.1, ns) and well-being (49.1 +/- 10.7 vs. 46.5 +/- 12.7, ns) scores were not. Parameters of perceived locus of control were (multiple v conventional): personal (self), 24.5 +/- 5.0 vs. 22.3 +/- 5.9, P < 0.05; medical (doctor), 11.8 +/- 5.1 vs. 10.8 +/- 5.8, ns; situational (chance), 7.9 +/- 5.1 vs. 8.9 +/- 5.9, ns. In multiple regression of HbA1c versus multiple variables only insulin regime (P < 0.001) was significant. We conclude that in routine clinical practice the use of intensive insulin regimes are associated with worse glycaemic control despite patients being marginally more knowledgeable and self directed.

Glycaemia control in diabetes mellitus. Towards the normal profile?

The Diabetes Control and Complications Trial and the Stockholm Study have conclusively demonstrated that improving the blood glucose control in patients with insulin-dependent diabetes mellitus (IDDM) reduces the risk of developing retinopathy, nephropathy and neuropathy. Each patient with IDDM should be carefully evaluated for the appropriateness of institution of an intensive insulin treatment programme. In particular, the risk of severe hypoglycaemia must be considered and the goals modified if necessary to reduce the risk. Successful implementation of an intensive treatment programme requires an experienced healthcare team and a knowledgeable and well motivated cooperative patient. Several variations of intensive treatment programmes can be used, with no definite superiority of one treatment method over the others. Individualization is the key to success. Each programme has the same general principles. Regular insulin is used to control the postprandial glucose excursion and a slow infusion of regular insulin by a pump or injected intermediate or long-acting insulin is used to balance fasting glucose utilisation and production. The treatment will not be successful without self-monitoring of blood glucose by the patient and frequent adjustment of the insulin doses to compensate for variations in blood glucose levels, diet and activity. The treatment should be followed with quarterly glycated haemoglobin determinations and a regular follow-up plan. During follow-up the main challenge for the healthcare team will be to maintain motivation in the patient and to assist with behaviour modification. A detailed understanding of intensive treatment programmes may be beyond the skill of the average primary care physician, but any physician caring for patients with diabetes will benefit from an understanding of the general treatment principles outlined in this article.

Pre-mixed insulin delivered by disposable pen in the management of children with diabetes

Pre-mixed insulin preparations are being used increasingly in the management of children with IDDM. Recently this form of insulin has been produced in a disposable insulin pen device. An open randomized 3-month crossover study was conducted to compare glycaemic control on a self-titrating insulin regimen with a pre-mixed (30:70) preparation, both given twice daily. The pre-mixed preparation was delivered by disposable pen. Forty children (age range 7-16 yr) entered the study. Mean +/- SEM glycosylated haemoglobin (HbA1 %) at the start of the study (13.1 +/- 0.6) compared with values at the end of the self-titrating (11.8 +/- 0.5) and pre-mixed periods (12.5 +/- 0.5), as well as blood glucose profiles taken at 3-weekly intervals, showed no significant change. Fourteen of the children were on insulin ratios other than 30:70 (range 10:90 to 50:50) and were unaffected by the switch (HbA1 at the start of the study 12.7 +/- 1; at the end of the self-titrating 11.5 +/- 0.8; and pre-mixed period 12.5 +/- 0.8). Twenty-one children continued on the pen for a further 12 months with no deterioration in control (HbA1 at the beginning and end of this period being 11.9 +/- 0.7 and 11.0 +/- 0.7, respectively). The children (95%) preferred the disposable pen and pre-mixed insulin regimen. Switching to pre-mixed insulin, while not improving, has no detrimental effect on glycaemic control.

Audit of the change from twice daily to basal-bolus insulin regimens in insulin-dependent diabetes

Basal-bolus insulin regimens have become popular with patients, but clinicians' enthusiasm for their use has been tempered by a number of reports that suggest that these regimens do not improve overall glycemic control when compared with conventional, twice daily, regimens. Indeed, it has been suggested that basal-bolus regimens may be abused by certain patients leading to an increase in body weight and deterioration in glycemic control. This paper reports the results of a retrospective audit of 145 insulin-dependent diabetic patients changed from conventional insulin therapy to a basal-bolus insulin regimen. After 3 months on the basal-bolus regimen, a small but significant fall in total insulin (10%; p < 0.001) and intermediate-acting insulin (50%; p < 0.001) dose was recorded. During this time period serum fructosamine measurements also fell by 10% (p < 0.001) indicating a small but significant improvement in glycemic control. Body-mass index (BMI) and body weight data did not support the view that basal-bolus regimens lead to an increase in body weight. Analysis of the data by gender did not support the view that the basal-bolus insulin regimen is prone to abuse by female patients.

Multiple daily insulin injections improve self-confidence

The efficacy and psychosocial effects of multiple daily insulin injections (three preprandial injections of short-acting insulin (NovoPen) and once daily, bedtime extended-acting insulin) were compared with those of twice daily combinations of short- and intermediate-acting insulin, in a randomized crossover study (two 6-month periods), in 16 adult diabetic patients. HbA1 was not significantly different for the two treatment modalities (8.2 +/- 0.4 vs 7.6 +/- 0.4%). With the pen-injector regimen significantly less state anxiety (36.0 +/- 2.5 vs 39.5 +/- 2.7; p less than 0.05) was found than with the conventional syringe regimen. The patients tended to experience a better self-concept as having diabetes (32.0 +/- 2.1 vs 37.7 +/- 3.0; p less than 0.06), as well as less external ('chance') orientation (18.5 +/- 1.2 vs 20.7 +/- 1.6; p = 0.09) with the pen-injector regimen. A subgroup of patients with lower trait anxiety scores experienced less state anxiety during the pen-injector regimen than during twice daily insulin injections (30.6 +/- 2.6 vs 34.3 +/- 2.7; p less than 0.05). However, this subgroup tended to be less positive about injecting insulin during the pen-injector regimen (34.8 +/- 3.6 vs 29.6 +/- 4.0; p less than 0.08). The subgroup with higher trait anxiety scores experienced a better self-concept as having diabetes (35.3 +/- 2.3 vs 40.1 +/- 2.6; p less than 0.05) and a tendency towards less physician orientation (15.8 +/- 1.8 vs 19.6 +/- 2.7; p less than 0.07) with the pen-injector regimen. Thirteen patients continued with the pen-injector regimen.

Improvement in morning hyperglycaemia with basal human ultratard and prandial human actrapid insulin--a comparison of multiple injection regimens

Three 'pen'-administered multiple injection regimens have been compared with twice daily insulin injection regimens by means of 24-h profiles of plasma glucose and free insulin concentrations. Ten Type 1 diabetic patients received their usual twice daily insulin regimen and were then randomized to receive the same total daily insulin dose in four divided doses using (1) 50:50 premixed soluble and isophane, (2) 30:70 premixed soluble and isophane, and (3) preprandial soluble and evening crystalline-zinc insulins. Profiles were performed after 1 week on each regimen. Plasma glucose concentrations were similar during the twice daily regimen and the two premixed regimens, rising during the early hours of the morning to a peak between 0900 and 0930 h of 13.8 +/- 2.8 (+/- SD) mmol l-1 on the twice daily regimen, 13.6 +/- 5.3 mmol l-1 on the premixed 50:50 regimen, and 13.5 +/- 4.2 mmol-1 on the premixed 30:70 regimen. With the basal and prandial regimen, overnight plasma glucose concentrations were higher than with the other regimens between 2400 and 0300 h (p less than 0.05). Concentrations then fell until breakfast, and rose after this meal to a peak of 9.5 +/- 4.3 mmol l-1 (p less than 0.01). Mean plasma glucose concentrations were significantly lower than on the other three regimens between 0830 and 1100 h (p less than 0.05). Less variability was observed in 24-h mean plasma glucose concentrations during the basal and prandial regimen than during the other three regimens.

An indwelling subcutaneous FEP cannula for intermittent insulin injection: patient experience and effect on diabetic control

The acceptability and efficacy of injecting insulin through a subcutaneous FEP cannula (to reduce the frequency of needle pricks) compared with conventional multiple injection therapy was examined in a cross-over study. Thirty-two insulin-dependent diabetic patients injected through the cannula for 10 weeks using a pen injector, followed by 10 weeks using the injector alone, or vice versa. Rapid-acting insulin was given before meals and intermediate-acting insulin at bedtime. Blood glucose control was not affected by cannula use (glycosylated haemoglobin: cannula, 8.6 +/- 0.3%; no cannula, 8.6 +/- 0.3%). Twenty-two of the 30 patients completing the study preferred to use the cannula and 21 requested to continue using it. There were no complications associated with its use.

Diabetic ketoacidosis during NovoPen therapy

To improve flexibility and acceptability of diabetic management five patients (age 15-26 years) were changed to NovoPen therapy (Human Actrapid Insulin 3 x daily + Human Ultratard Insulin at night). Diabetic ketoacidosis developed within 2-4 months of commencing this regimen and in one patient twice in only 4 weeks. All failed to increase their insulin dose in response to hyperglycaemia and two patients omitted insulin when they did not take meals believing this to be appropriate irrespective of the prevailing blood glucose. The NovoPen regimen may increase the risk of diabetic ketoacidosis in patients who do not monitor and control their diabetes assiduously and should not be seen as a solution for poorly motivated or ill-educated patients.